Young Afghans experience violence that is ongoing and not just confined to acts of war

Young Afghans experience violence that is ongoing and not confined to acts of war, concludes an Article published Online First and in an upcoming edition of The Lancet. The study emphasises the value of school-based initiatives to address child mental health, and the importance of understanding trauma in the context of everyday forms of suffering, violence, and adversity. The Article is based on research funded by the Wellcome Trust and written by Professor Catherine Panter-Brick, Durham University, UK, and colleagues.

Studies in Afghanistan have shown substantial mental health problems in adults, but evidence relating to children is sparse. The authors did a survey of young people (11󈝼 years old) in the country to assess mental health, traumatic experiences, and social functioning. The study involved interviewing 1,011 children, 1,011 caregivers, and 358 teachers, all randomly sampled from 25 government-operated schools within three deliberately chosen central and northern areas (Kabul, Bamyan, and Mazar-e-Sharif). Probable psychiatric disorder and social functioning in students was assessed, as was the mental health of caregivers. Risk factors for child mental health and reports of traumatic experiences were also analysed.

The researchers found an association between all child psychiatric outcomes and both trauma exposure and caregiver mental health. Around 22% of children met the criteria for probable psychiatric disorder, with girls around two-and-a-half times more likely to have disorders than boys. Children who had suffered five or more traumatic events were two-and-a-half times more likely to have a psychiatric disorder, as well as three times more likely to report symptoms of post-traumatic stress than those who had experienced four events or less. Caregiver mental health was correlated to the wellbeing of the children under their care: there was a 10% increase in the likelihood of child psychiatric disorder for each and every symptom of psychological distress reported by caregivers. Children living in Kabul were more likely to have a psychiatric disorder and symptoms of post-traumatic stress than those living in Bamyan or Mazar-e-Sharif. The study also provides evidence of the fortitude and resilience among Afghan children in coping with violence and day-to-day adversity. Students, caregivers, and children reported many symptoms of mental health difficulties, but also rated their social functioning positively.

The authors say: "Afghan Government policy has recognised the need for public

health interventions to alleviate trauma, mental health disorders, and psychological distress in the general population. There is, however, an acute shortage of qualified mental health care practitioners, constraints on the current provision of basic health and social services, and inherent challenges in creating effective youth-focused programmes."

They conclude: "In Afghanistan, there is a spectrum of violence--ranging from armed insurgency to family conflict--which generates sudden pain and persistent suffering. Our data suggest that, in Afghan children's lives, everyday violence matters just as much as militarised violence in the recollection of traumatic experiences...Our study emphasises the value of school-based initiatives to address child mental health, and the importance of understanding trauma in the context of everyday forms of suffering, violence, and adversity."

In an accompanying Comment, Dr Andrew Dawes, University of Cape Town, South Africa, and University of Oxford, UK, and Dr Alan J. Flisher, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa, caution that school-based interventions may not be feasible due to the strain under which the Afghan education system operates--namely that inadequate resources could mean teachers do not have enough time and emotional resources to monitor child mental health. They conclude that there need to be more investigations of this kind in different settings, and that interventions need to draw on traditional systems of support as much as modern methods.

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